title: Revitalizing the HIV response in Pakistan: a systematic review and policy implications.
abstract: BACKGROUND
  We sought to describe the epidemiology of HIV in Pakistan and prioritize interventions to improve the effectiveness and efficiency of the response to HIV.
  
  
  METHODS
  We conducted a systematic review of the epidemiology of HIV in Pakistan. Data sources included PUBMED and EMBASE and unpublished reports from public, non-governmental organizations and provincial and national stakeholders. We focused on findings from the last 5 years and only evaluated data before 2005 on at risk groups where there were insufficient data published after 2005. A population attributable risk analysis was conducted to estimate the burden of HIV among most at risk populations (people who inject drugs, female sex workers, male sex workers, Hijra or transgender sex workers and men who have sex with men).
  
  
  RESULTS
  Pakistan has a concentrated epidemic of HIV-1 among most at risk populations with very low prevalence rates in the general population (0.04%). The majority of current HIV infections are estimated to occur among four at risk populations, despite their accounting for under 2% of all adults. Injecting drug users accounted for 36.4% of HIV cases - the largest share of infections in any one group. Female, male and transgender sex workers accounted for 24%, 12% and 17.5% respectively, a cumulative population attributable risk of 53.5% of all infections occurring among sex workers.
  
  
  CONCLUSIONS
  Pakistan must continue to invest in targeted, evidence-based interventions to prevent the spread of HIV and curb the epidemic trajectory in Pakistan. A comprehensive range of services should include needle and syringe exchange, opiate substitution therapy for people who inject drugs, outreach and engagement with injecting drug users, Hijra' community as well as male and female sex workers and their clients and improved linkage between services and voluntary counseling, testing and anti-retroviral therapy.
authors.affiliation: Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA. Electronic address: sosingh@jhsph.edu.
authors.forename: Sonal
authors.initials: S
authors.lastname: Singh
authors.affiliation: Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Marco
authors.initials: M
authors.lastname: Ambrosio
authors.affiliation: Global HIV Program, The World Bank, Washington, DC, USA.
authors.forename: Iris
authors.initials: I
authors.lastname: Semini
authors.affiliation: Country Office Pakistan, UNAIDS, Pakistan.
authors.forename: Oussama
authors.initials: O
authors.lastname: Tawil
authors.affiliation: Country Office Pakistan, UNAIDS, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Saleem
authors.affiliation: National AIDS Control Programme, Ministry of Inter-Provincial Coordination, Pakistan.
authors.forename: Muhammad
authors.initials: M
authors.lastname: Imran
authors.affiliation: Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Chris
authors.initials: C
authors.lastname: Beyrer
mesh_terms: D015658:HIV Infections / Q000150:complications / Q000453:epidemiology* / Q000517:prevention & control* / Q000628:therapy; D006287:Health Planning Guidelines; D006801:Humans; D010154:Pakistan / Q000453:epidemiology; D015995:Prevalence; D040242:Risk Reduction Behavior; D060386:Sex Workers / Q000706:statistics & numerical data; D015819:Substance Abuse, Intravenous / Q000150:complications / Q000453:epidemiology; D035862:Vulnerable Populations / Q000706:statistics & numerical data
keywords: Concentrated epidemics; HIV; Pakistan; People who inject drugs